Though doctors and researchers have been reflecting on therapeutic interventions to come to grips with the problem, we are still in the early stages of setting up system-wide countervailing strategies and policies. Indeed, only recently have system-wide efforts started gaining momentum.

In September 2016, the General Assembly of the United Nations gathered to discuss AMR. This was only the fourth time in history that a health issue had prompted such action, demonstrating the importance of the problem globally. The result was a draft resolution that called for action to ensure the appropriate use of antimicrobials across animal and human health.

A key strategy involves the implementation of antimicrobial stewardship (AMS), that is, activities designed to optimise the use of antimicrobial drugs. The objective is to ensure that people who need these drugs receive them, but also to avoid unnecessary use, minimise toxicity of therapy, and importantly, minimise the impact of the selection of pathogens with antimicrobial resistance.

A key objective of Australia’s national research agenda and health policy should be to develop effective AMS systems in all the sectors in which antimicrobials are primarily used. This includes hospitals, community care settings (including general practice and aged care settings), veterinary medicine and agriculture. This takes into account the concept of One Health, which posits that human health, animal health and the environment are all interconnected and that antimicrobial use in one sector will influence another.

Australian stewardship – advancements in the field

At the outset, it should be noted that Australia has been fairly advanced in terms of its thinking on AMS, at least with respect to hospitals and the tertiary care sector, and is internationally recognised as a leader in the field.

The ACSQHC is working on updating a publication, Antimicrobial stewardship in Australian hospitals, which was released in 2011 and helped to guide activity in the sector. The new book, which is due for publication in 2017, will expand on areas such as community care, aged care, paediatrics, veterinary and livestock medicine, and dental care.

An update of the National Safety and Quality Health Service hospital standards for accreditation is in progress. The standards for AMS programs are set to be further refined in light of hospitals’ experience of implementation. There is likely to be an emphasis on delineating restriction rules and approval processes, auditing and providing feedback to prescribers, and monitoring the appropriateness of use.

The national clinical care standards for AMS released in 2014 are directed towards individual prescribers and their patients. These standards are intended to ensure that practitioners use best practice when prescribing antimicrobials, and that patients are properly informed about appropriate antimicrobial use.

These are huge achievements and help to increase awareness and clearly define expectations regarding antimicrobial use. Prescribers and consumers are being asked to rethink the way we approach antimicrobial drugs, to recognise that they are a “precious resource”, and that their use needs to be rationalised to ensure that they are protected and remain effective for future generations.

Auditing antimicrobial prescribing practices in Australia

In order to take action to improve prescribing practices, we first need to understand what is currently happening and then identify where improvement is required. Gathering such data has previously been very problematic. A large body of work has been undertaken by the National Centre for Antimicrobial Stewardship (NCAS) to develop standardised auditing tools that will help provide more meaningful data on the appropriateness of antimicrobial use.

The National Antimicrobial Prescribing Survey (NAPS) is a voluntary audit undertaken annually by hospitals from across Australia. It provides a snapshot of antimicrobial prescribing across public and private hospitals of all sizes, in different geographic locations, and with varied levels of expert support. The audit enables assessments of the appropriateness of prescriptions, and is a key component of the incipient Antimicrobial Use and Resistance in Australia (AURA) Surveillance System, which the ACSQHC has established with funding from the Department of Health.

International studies often cite that half of all antimicrobial prescriptions are inappropriate. In fact, the Australian NAPS done since 2013 show that Australia has higher appropriateness rates, at around 70% (although a goal of more than 95% has been set). Poor prescribing has been identified in certain areas, such as the treatment of respiratory infections (e.g., chronic obstructive pulmonary disease) and surgical prophylaxis. These findings help to target the activity of AMS programs within hospitals, and can directly inform broader initiatives such as national guidelines.

The survey’s remit, hitherto only encompassing hospitals, has now been extended to the aged care sector as well. A report released in 2016 and based on an audit of Australian aged care facilities showed disturbing rates of prolonged antimicrobial prescriptions and poor documentation of indications for use among residents.

Areas of need

It has been shown that the rates of antimicrobial prescribing in the Australian community on a per capita basis are about 10% above the Organisation for Economic Co-operation and Development average. We do not, however, have a detailed understanding of the appropriateness of such prescribing, and thus the areas requiring action are not yet entirely clear. There is an urgent need to gather such data and to meaningfully analyse it to drive improvement activities. NPS MedicineWise has been an active group in this area, but more action is urgently required.

Similarly, the level of detail on antimicrobial usage in the veterinary and agricultural sectors is currently inadequate in Australia. Although data on volumes of drugs imported for animal use confirm that Australia has very low levels of antimicrobial use, the reasons for use and the appropriateness of such use are poorly understood. NCAS is undertaking research into antimicrobial usage for both companion animals and livestock.

Another challenge facing AMS researchers in Australia is the lack of data linkage between antimicrobial usage and antimicrobial resistance. The patterns of pathogens being identified in patients are likely to be influenced by patterns of antimicrobial drug exposure in the local environment (for humans, animals and agriculture). To date, we have a poor understanding of the interrelationships between these.

How do we improve prescribing behaviour?

There is no doubt that urgent action needs to be taken to improve prescribing behaviours. In busy health care settings, we know that to be successful, AMS solutions must ultimately fit comfortably into the clinical workflow. Information technology, therefore, will play a crucial role – either at the “front-end”, providing decision support about antimicrobial choice, or at the “back-end”, aggregating data for effective and useful reporting.

One program, Guidance, developed at the Royal Melbourne Hospital, has been adopted by over 60 hospitals across Australia since 2005 to assist their AMS programs. As the innovation arm of NCAS, the Guidance team are now working with hospitals to implement electronic management systems for AMS. A key aim is to support interoperability between hospital systems, stewardship programs and NAPS. It is imperative that community prescribing software follows suit. It should be integrated with appropriate decision support to promote better prescribing practices in accordance with Australian recommendations. This will, however, need to be guided by careful health services research to ensure that solutions meet the needs of prescribers across each health care sector.

It is important to recognise that antimicrobial stewardship is not just about the prevention of antimicrobial resistance; its focus, first and foremost, is patient safety.

Professor Karin Thursky is the director of the NHMRC-CRE National Centre for Antimicrobial Stewardship, director of the Guidance Group at the Royal Melbourne Hospital, and deputy head of Infectious Diseases at the Peter MacCallum Cancer Centre in Melbourne.

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3 thoughts on “Milestones, challenges in antimicrobial stewardship”

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The JETCAR report (1) and at the Pan Pacific Conference in Brisbane last year, from Prof Collignan “”Much of this antibiotic resistance, especially to third-generation cephalosporins and fluoroquinolones, is related to resistance that develops in bacteria carried by food animals and results from the misuse of antibiotics in these animals” . Not surprisingly, pets of unwell patients often acquire the resistant bacteria from their unwell owner and remain an ongoing source.(2) . 11.9% of equine vets carry MRSA with unequivocal human – animal spread.

Veterinary surgeons have free rein to prescribe almost any drug the customer will pay for and this includes all the drugs/antibiotics that human doctors must seek formal permission or an authority prescription to use.

The Veterinary profession has a significantly greater prescribing freedom than the medical profession, however this comes on the back of a significantly less theoretical training regime.
I have personally witnessed animal production (dairy) farms with plastic mop buckets full of antibiotics (including vancomycin and 3rd generation broad spectrum antibiotics) .

The “One Health” approach is an incomprehensibly overdue and possibly too late approach that acknowledges that humans are just another animal species. Separation of the veterinary and medical community has resulted in some major health declines, antibiotic resistance being but one of them.

Alert medicos by all means however the primary change has to come from the comparatively unregulated Veterinary profession. We should be training and working alongside each other.

Most of the antibiotics pressure comes from the animal and livestock industry, followed by general practitioners. Moreover, significant portion of antibiotics resistance mechanisms are linked to resistance to disinfectants. Government funding should be put towards programs restricting use of antibiotics in farming, as well as restricting sale of disinfectants for household use, led by people who can effect changes in those industries.

It is not only the prescription of antibiotics to the general public and live stock industry that is important in reducing the emergence and incidence of antimicrobial resistance, funding to work out strategies for enhancing the antimicrobial efficacy of the currently available and used antimicrobials, particularly for bacterial biofilms, also needs to be provided.

Considerable funding has been and is being poured into identifying the antibiotics to which antimicrobial resistance by bacterial pathogens has and is developing. Now is the time to pour funding into the finding of ways to eliminate or reduce the incidence of antimicrobial resistance.